Robotic nipple-sparing mastectomy complication rate compared to traditional nipple-sparing mastectomy: a systematic review and meta-analysis

Emerging Role of Robotic Surgery in the Breast

In recent years, there has been increased adoption of robotic technology in oncologic breast surgery, particularly with the use of robotic nipple sparing mastectomy (r-NSM). Here we review the emergence of robotic-assisted surgery in breast procedures, and discuss the safety, limited oncologic outcomes, apparent advantages, and potential limitations of r-NSM compared to conventional open-NSM (c-NSM). Limited data suggests that robotic-assisted surgery offers smaller incisions and potential for improved cosmesis and ergonomic advantage when compared to c-NSM. Similar periprocedural complication rates are seen with r-NSM compared with c-NSM. Short-term oncologic follow-up is reassuring however, but remains early and continues to be investigated. The increased cost of r-NSM compared to open surgery and feasibility of widespread adoption of the procedure are important considerations that need to be evaluated. Randomized trials are currently ongoing to address the apparent advantages, oncologic outcomes, and cost/feasibility of robotic breast surgery.

Evaluating the utility of robotic axillary lymph node dissection in patients with invasive breast cancer: a systematic review

Robot-assisted axillary lymph node dissection (RALND) has been proposed to improve surgical and oncological outcomes for patients with breast cancer. To perform a systematic review of current literature evaluating RALND in patients with invasive breast cancer. A systematic search was performed in accordance with the PRISMA guidelines. Studies outlining outcomes following RALND were included. Two studies involving 92 patients were included in this review. Of these, 41 underwent RALND using the da Vinci© robotic system (44.57%), and 51 underwent conventional axillary lymph node dissection (CALND) (55.43%). There was no significant difference observed with respect to intra-operative blood loss or duration of procedure in those undergoing CALND and RALND (P > 0.050). One study reported a significant difference in lymphoedema rates in support of RALND (6.67% vs 26.67%, P = 0.038). Overall, data in relation to postoperative fat necrosis (10.00% vs 33.33%, P = 0.028), wound infection rates (3.33% vs. 20.00%, P = 0.044), and wound ≤ 40 mm in length (63.63% vs. 19.05%, P = 0.020) supported RALND. Oncological outcomes were only reported in one of the studies, which concluded that there was no local or metastatic recurrence in either group at 3-month follow-up. These provisional results support RALND as a safe alternative to CALND. Notwithstanding, the paucity of data limits the robustness of conclusions which may be drawn surrounding the adoption of RALND as the standard of care. Further high-quality studies are required to ratify these findings.

Surgical outcomes of robotic versus conventional autologous breast reconstruction: a systematic review and meta-analysis

Breast reconstruction is an integral part of breast cancer management. Conventional techniques of flap harvesting for autologous breast reconstruction are associated with considerable complications. Robotic surgery has enabled a new spectrum of minimally invasive breast surgeries. The current systematic review and meta-analysis study was designed to retrieve the surgical and clinical outcomes of robotic versus conventional techniques for autologous breast reconstruction. An extensive systematic literature review was performed from inception to 25 April 2023. All clinical studies comparing the outcomes of robotic and conventional autologous breast reconstruction were included for meta-analysis. The present meta-analysis included seven articles consisting of 783 patients. Of them, 263 patients received robotic breast reconstruction, while 520 patients received conventional technique. Of note, 477 patients received latissimus dorsi flap (LDF) and 306 were subjected to deep inferior epigastric artery perforator (DIEP) flap. There was a significantly prolonged duration of surgery (MD 58.36;95% CI 32.05,84.67;P < 0.001) and duration of anaesthesia (MD 47;95% CI 16.23,77.77;P = 0.003) among patients who underwent robotic surgery. There was a similar risk of complications between robotic and conventional surgeries. The mean level of pain intensity was significantly lower among patients who received robotic breast surgery (MD- 0.28;95% CI - 0.73,0.17; P = 0.22). There was prolonged length of hospitalization among patients with conventional DIEP flap surgery (MD- 0.59;95% CI - 1.13,- 0.05;P = 0.03). The present meta-analysis highlighted the feasibility, safety, and effectiveness of robotic autologous breast reconstruction. This included the successful harvesting of LDF and DIEP flap with acceptable surgical and functional outcomes.

Safety and Feasibility of Single-Port Robotic-Assisted Nipple-Sparing Mastectomy

Importance

Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery.

Objective

To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM).

Design, Setting, and Participants

An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care.

Intervention

Surgery using a single-port robot and the surgical technique of the authors.

Main Outcomes and Measures

Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation.

Results

Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%).

Conclusion and Relevance

In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT05245812.

Postoperative complications and surgical outcomes of robotic versus conventional nipple-sparing mastectomy in breast cancer: meta-analysis

BACKGROUND

Breast cancer is the most common cancer worldwide, with remarkable advances in early diagnosis, systemic treatments, and surgical techniques. Robotic nipple-sparing mastectomy has been trialled; however, the complication rates, surgical outcomes, and oncological safety of this approach remain obscure.

METHODS

A systematic search of the literature was conducted from conception until September 2022. Studies examining complications and operative variables where robotic nipple-sparing mastectomy was compared with conventional nipple-sparing mastectomy were included. Primary study outcomes were complications (Clavien-Dindo grade III complications, skin or nipple necrosis, seroma, haematoma, infection, implant loss, and wound dehiscence) and oncological safety (recurrence and positive margins). The secondary outcomes included operative variables, length of stay, cost-effectiveness, learning curve, and aesthetic outcome.

RESULTS

A total of seven studies of overall fair quality, involving 1674 patients, were included in the systematic review and meta-analysis. Grade 3 complications were reduced in robotic nipple-sparing mastectomy without statistical significance (OR 0.60 (95 per cent c.i. 0.35 to 1.05)). Nipple necrosis was significantly reduced in robotic nipple-sparing mastectomy (OR 0.54 (95 per cent c.i. 0.30 to 0.96); P = 0.03; I2 = 15 per cent). Operating time (mean difference +58.81 min (95 per cent c.i. +28.19 to +89.44 min); P = 0.0002) and length of stay (mean difference +1.23 days (95 per cent c.i. +0.64 to +1.81 days); P < 0.0001) were significantly increased in robotic nipple-sparing mastectomy, whereas the opposite was true for blood loss (mean difference -53.18 ml (95 per cent c.i. -71.78 to -34.58 ml); P < 0.0001).

CONCLUSION

Whilst still in its infancy, robotic breast surgery may become a viable option in breast surgery. Nonetheless, the oncological safety of this approach requires robust assessment.

Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P)

OBJECTIVE

To compare the clinical and patient-reported outcomes of minimal access and conventional nipple-sparing mastectomy (C-NSM). The secondary outcomes investigated included medical costs and oncological safety.

BACKGROUND

Minimal-access NSM has been increasingly applied in the treatment of patients with breast cancer. However, prospective multicenter trials comparing robotic-assisted NSM (R-NSM) versus C-NSM or endoscopic-assisted NSM (E-NSM) are lacking.

METHODS

A prospectively designed 3-arm multicenter, nonrandomized trial (NCT04037852) was conducted from October 1, 2019 to December 31, 2021, to compare R-NSM with C-NSM or E-NSM.

RESULTS

A total of 73 R-NSM, 74 C-NSM, and 84 E-NSM procedures were enrolled. The median wound length and operation time of C-NSM was (9 cm, 175 minutes), (4 cm, and 195 minutes) in R-NSM, and (4 cm and 222 minutes) in E-NSM. Complications were comparable among the groups. Better wound healing was observed in the minimal-access NSM group. The R-NSM procedure was 4000 and 2600 United States Dollars more expensive than C-NSM and E-NSM, respectively. Wound/scar and postoperative acute pain evaluation favored the use of minimal access NSM over C-NSM. Quality of life in terms of chronic breast/chest pain, mobility, and range of motion of the upper extremity showed no significant differences. The preliminary oncologic results showed no differences among the 3 groups.

CONCLUSIONS

R-NSM or E-NSM is a safe alternative if compared with C-NSM in terms of perioperative morbidities, especially with better wound healing. The advantage of minimal access groups was higher wound-related satisfaction. Higher costs remain one of the major limiting factors in the widespread adoption of R-NSM.

The Full Continuum of Robotic Breast Surgery: Robotic-assisted Mastectomy, Robotic DIEP Flap, and Robotic Supermicrosurgery

In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.

Robot-assisted Nipple Sparing Mastectomy: Recent Advancements and Ongoing Controversies

Purpose of review

The purpose of this review is to summarize the recent technical advancements in RNSM, describe the ongoing teaching programs, and discuss the ongoing controversies.

Recent findings

Robot-assisted nipple sparing mastectomy (RNSM) is the newest addition to the armamentarium of surgical techniques for patients who require a mastectomy. The potential benefits of using the da Vinci® Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) are the small 3D camera and lighting offering superior visualization, the Endowrist robotic instruments offering greater range of motion, and surgeon being at a seated position at the console rendering a more ergonomic operating position.

Summary

RNSM can potentially help overcome the technical difficulties of performing a conventional NSM. Further studies are needed to elucidate the oncologic safety and cost-effectiveness of RNSM.

Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.

Breast Cancer Surgery: New Issues

Since ancient times, breast cancer treatment has crucially relied on surgeons and clinicians making great efforts to find increasingly conservative approaches to cure the tumor. In the Halstedian era (mid-late 19th century), the predominant practice consisted of the radical and disfiguring removal of the breast, much to the detriment of women's psycho-physical well-being. Thanks to enlightened scientists such as Professor Umberto Veronesi, breast cancer surgery has since impressively progressed and adopted a much more conservative approach. Over the last three decades, a better understanding of tumor biology and of its significant biomarkers has made the assessment of genetic and molecular profiles increasingly important. At the same time, neo-adjuvant treatments have been introduced, and great improvements in genetics, imaging technologies and in both oncological and reconstructive surgical techniques have been made. The future of breast cancer management must now rest on an ever more precise and targeted type of surgery that, through an increasingly multidisciplinary and personalized approach, can ensure oncological radicality while offering the best possible quality of life.